A call to action: the global failure to effectively tackle maternal mortality rates
Authors: Asma Khalil, Athina Samara, Pat O'Brien, Conrado Milani Coutinho, Silvana Maria Quintana, Shamez N Ladhani
Journal: The Lancet Global Health (2023)

Maternal death rates are rising again in many countries, yet this alarming fact has gone largely unacknowledged in the medical and lay press. In 2020, one woman died every 2 min from preventable causes related to pregnancy.1WHOTrends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division.https://www.who.int/publications/i/item/9789240068759Date: Feb 23, 2023Date accessed: March 25, 2023Google Scholar This statistic represents approximately 800 women dying daily—a maternal mortality ratio (MMR) of 223 maternal deaths per 100 000 livebirths, which is far removed from the UN Sustainable Development Goal target 3.1 to reduce the global MMR to less than 70 deaths per 100 000 livebirths by 2030. Between 2000 and 2020 the global MMR declined by 34·8% (from 342 deaths per 100 000 livebirths to 223 deaths per 100 000 livebirths). During the period 2016–20, MMRs stagnated in 133 countries, and increased substantially in 17, mainly in western Europe, North America, Latin America, and the Caribbean. Between 2000 and 2020, eight countries recorded substantial increases in MMRs: Venezuela (182·8%), Cyprus (107%), Greece (101·1%), the USA (77·9%), Mauritius (62·1%), Puerto Rico (55·9%), Belize (51·3%), and the Dominican Republic (36·0%; figure A).1WHOTrends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division.https://www.who.int/publications/i/item/9789240068759Date: Feb 23, 2023Date accessed: March 25, 2023Google Scholar Differences between countries mask the true burden of mortality in countries with the highest MMRs. In three sub-Saharan African countries, the MMR in 2020 exceeded 1000 deaths per 100 000 livebirths: South Sudan (1223), Chad (1063), and Nigeria (1047; figure B). Nigeria alone recorded 82 000 deaths in 2020, representing 28·5% of global maternal deaths, while India, the Democratic Republic of the Congo, and Ethiopia each recorded over 10 000 deaths (figure C).1WHOTrends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division.https://www.who.int/publications/i/item/9789240068759Date: Feb 23, 2023Date accessed: March 25, 2023Google Scholar In the USA, the MMR increased from 20·1 deaths per 100 000 livebirths in 2019 to 23·8 deaths per 100 000 livebirths in 2020, and 32·9 deaths per 100 000 livebirths in 2021,3Knight M Bunch K Patel R et al.Saving lives, improving mothers' care core report—lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018–20. National Perinatal Epidemiology Unit, University of Oxford, Oxford2022http://hubble-live-assets.s3.amazonaws.com/birth-companions/file_asset/file/590/MBRRACE-UK_Maternal_MAIN_Report_2022_v10.pdfDate accessed: March 30, 2023Google Scholar with significantly higher mortality rates recorded among Black women than among White and Hispanic women. MMRs increased across all age groups in the USA between 2020 and 2021, with a strong age gradient ranging from 20·4 deaths per 100 000 livebirths in women younger than 25 years to 138·5 deaths per 100 000 livebirths in those older than 40 years.4Hoyert DL Maternal mortality rates in the United States. National Center for Health Statistics Health E-Stats.https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.pdfDate: 2021Date accessed: March 28, 2023Google Scholar Territorial disparities within countries have also been reported, such as in Brazil, where the MMR reached 74·7 deaths per 100 000 livebirths in 2020; excess maternal deaths reflected socioeconomic inequalities and poor access to maternal health-care services.5Orellana J Jacques N Leventhal DGP Marrero L Morón-Duarte LS Excess maternal mortality in Brazil: regional inequalities and trajectories during the COVID-19 epidemic.PLoS One. 2022; 17e0275333Crossref Scopus (4) Google Scholar As of April 15, 2023, preliminary data in the Brazilian Ministry of Health live reporting system6Department of Epidemiological Analysis and Surveillance of Noncommunicable DiseasesMaternal mortality monitoring panel. Brazilian Ministry of Health, April, 2023https://svs.aids.gov.br/daent/centrais-de-conteudos/paineis-de-monitoramento/mortalidade/materna/Date accessed: April 15, 2023Google Scholar report 2941 maternal deaths among 2 672 046 livebirths in 2021 (ie, a MMR of 110·1; figure A). In the WHO European region, approximately 1000 women died due to complications related to pregnancy in 2020.7WHOMaternal mortality rates stagnate in some countries in Europe despite recent progress, new data warn. World Health Organization, March 1, 2023https://www.who.int/europe/news/item/01-03-2023-maternal-mortality-ratesstagnate-in-some-countries-in-europe-despite-recent-progress--new-data-warnDate accessed: March 28, 2023Google Scholar In the UK and Ireland, the MMR increased by 51% in the period 2018–20 compared with the MMR between 2015 and 2017 (6·04 deaths per 100 000 livebirths vs 4·01 deaths per 100 000 livebirths).3Knight M Bunch K Patel R et al.Saving lives, improving mothers' care core report—lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018–20. National Perinatal Epidemiology Unit, University of Oxford, Oxford2022http://hubble-live-assets.s3.amazonaws.com/birth-companions/file_asset/file/590/MBRRACE-UK_Maternal_MAIN_Report_2022_v10.pdfDate accessed: March 30, 2023Google Scholar Black and Asian women had a greater likelihood of death than White women (3·7 times higher and 1·8 times higher, respectively). According to WHO, evaluating the effect of COVID-19 on maternal mortality is not yet possible as only approximately 20% of countries have reported data for 2020. In the USA, COVID-19 was a contributing factor in a quarter of all maternal deaths in 2020–21.8US Government Accountability OfficeMaternal health outcomes worsened and disparities persisted during the pandemic.https://www.gao.gov/assets/gao-23-105871.pdfDate: Oct, 2022Date accessed: March 21, 2023Google Scholar The Pan American Health Organization reported a 20-year setback in maternal health in the Americas due to the COVID-19 pandemic, with the 16·4% reduction in MMR observed between 1990 and 2015 being followed by a 15% increase between 2016 and 2020.9Pan American Health OrganizationPAHO and partners launch campaign to reduce maternal mortality in Latin America and the Caribbean. Pan American Health Organization, March 8, 2023https://www.paho.org/en/news/8-3-2023-paho-and-partners-launch-campaign-reduce-maternal-mortality-latin-america-and#:~:text=Washington%20DC%2C%20March%208%2C%202023,15%25%20between%202016%20and%202020Date accessed: April 20, 2023Google Scholar In Brazil, the excess maternal mortality in 2020 was 1·40 deaths per 100 000 livebirths, far higher than predicted, even when considering the excess mortality for women of childbearing age due to COVID-19.10Guimarães RM Reis LGC de Souza Mendes Gomes MA Magluta C de Freitas CM Portela MC Tracking excess of maternal deaths associated with COVID-19 in Brazil: a nationwide analysis.BMC Pregnancy Childbirth. 2023; 23: 22Crossref PubMed Scopus (3) Google Scholar Racial and socioeconomic disparities were also identified in the excess maternal mortality, with women who died due to complications related to pregnancy having 44%, 61%, and 28% higher odds of being Black, living in a rural area, and being hospitalised outside their municipality of residence, respectively, than the control group.10Guimarães RM Reis LGC de Souza Mendes Gomes MA Magluta C de Freitas CM Portela MC Tracking excess of maternal deaths associated with COVID-19 in Brazil: a nationwide analysis.BMC Pregnancy Childbirth. 2023; 23: 22Crossref PubMed Scopus (3) Google Scholar In Chile, the MMR increased from 19·2 deaths per 100 000 livebirths in 2019 to 28·1 deaths per 100 000 livebirths in 2020, reversing a 30-year decline. Only 29% of these excess deaths were directly attributed to COVID-19.11Gonzalez R Merialdi M Viviani P et al.Indirect effect of COVID-19 on maternal mortality in Chile.J Matern Fetal Neonatal Med. 2023; 362183758Crossref Scopus (1) Google Scholar There was a clear reduction in the utilisation of maternal health-care services during the COVID-19 pandemic in both low-income and middle-income countries (LMICs) and high-income countries (HICs). During the period March–December, 2020, initial antenatal care visits decreased by 32% and institutional births decreased by almost 16%.12Aranda Z Binde T Tashman K et al.Disruptions in maternal health service use during the COVID-19 pandemic in 2020: experiences from 37 health facilities in low-income and middle-income countries.BMJ Glob Health. 2022; 7e007247Crossref PubMed Scopus (37) Google Scholar Moreover, epidemiological data in Brazil showed that among the pregnant women who died due to COVID-19 in 2021, 59% had no previous risk factors or comorbidities.10Guimarães RM Reis LGC de Souza Mendes Gomes MA Magluta C de Freitas CM Portela MC Tracking excess of maternal deaths associated with COVID-19 in Brazil: a nationwide analysis.BMC Pregnancy Childbirth. 2023; 23: 22Crossref PubMed Scopus (3) Google Scholar The contribution of the pandemic to the increase in maternal mortality is, therefore, probably due to both infection with SARS-CoV-2 and the detrimental effect of the pandemic on health-care services. As population immunity to SARS-CoV-2 increases, the contribution of infections to maternal mortality is expected to decrease. Unfortunately, women's health care has been disproportionately affected by the pandemic, particularly in LMICs.13Chmielewska B Barratt I Townsend R et al.Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis.Lancet Glob Health. 2021; 9: e759-e772Summary Full Text Full Text PDF PubMed Scopus (466) Google Scholar The fact that maternal mortality is rising again is a major scandal in both LMICs and HICs. We call on the global health-care community, including the UN, WHO, national governments, and health-care professionals, to bolster the provision and quality of maternal health care, redouble efforts to reduce MMRs again, and rectify the damage wrought by the pandemic on women's health-care services. The need to collect high-quality, real-time data on the provision of maternity care and pregnancy outcomes in all countries is more pressing than ever. AK is Vice-President of the Royal College of Obstetricians and Gynaecologists. All other authors declare no competing interests.